RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04357
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Voice Interceptor Trainee, medically separated for “chronic radiating low back pain [LBP],” and “radiating pain and slight weakness of dorsiflexion of the left foot,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The VA rated him higher for his conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20050915	VARD - 20060918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating LBP	5243	10%	Degenerative Joint Disease of L5-S1	5243	10%	20060503	
Radiating Pain and Slight Weakness of Dorsiflexion of the Left Foot	5243-8520	10%	Left Lumbar Radiculopathy 	8520	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Radiating Low Back Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s complained of intermittent back pain radiating into his legs with numbness and weakness in his left leg and foot that began in October 2003 after a 4 mile run.  The pain became persistent requiring treatment in May 2004. Lumbar spine X-rays in June 2004 demonstrated mild degenerative changes of the lower thoracic spine and minimal convex left curvature of the lumbar spine. After 3 months of pain management, the CI had some improvement.  Magnetic resonance imaging (MRI) of the lumbar spine dated 4 October 2004 showed an L5-S1 paracentral disc protrusion of 5 mm and an annular tear.  A thoracic MRI on 1 November 2004 was normal.  Right leg symptoms began in February 2005.  At the time of a neurosurgery consult on 8 November 2004, the CI reported back pain and his left anterior thigh “falls asleep.”  The CI denied weakness or numbness in his feet or legs or changes in his bowel or bladder habits.  On examination, he displayed a normal gait and spinal contour, no paraspinal muscle spasm, normal reflexes, and normal strength; and, examination maneuvers for radicular signs were positive on the left and negative on the right.  Palpation of the spine showed a moderate amount of tenderness in the paraspinous muscles.  Range of motion (ROM) was described as reasonably good.  On review the MRI showed evidence at L5-S1 of a significant disc degeneration and a slight left sided protruding disc that abutted the nerve root.  The neurosurgeon opined the CI did not clearly have an S1 radiculopathy and thought much of his low back and thoracic pain was due to muscle tension and perhaps a chronic strain injury.   A physical medicine specialist reported on 11 January 2005 that the CI’s low back pain was his most active symptom (L > R), which radiated down his left posterior leg and was associated with prolonged sitting and standing.  Elavil (amitriptyline for nerve pain) dose was increased and Neurontin (gabapentin for nerve pain) was prescribed.  At the 17 January 2005 follow-up, the CI reported increasing pain in the left buttock radiating down his leg with numbness and tingling to the foot with any physical activity. The assessment was progression of left S1 radicular symptoms with slight weakness, numbness, tingling and persistent pain.  There was no surgical indication, and conservative treatment including trigger point injections and physical therapy did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “upper and lower back pain” for PEB adjudication.

At the MEB examination dated April 2005, 8 months prior to separation, the CI reported back pain and numbness and tingling down the left side.  Physical examination showed bilateral thoracic and lumbar spasms.  The MEB NARSUM examination on 23 May 2005 (7 months prior to separation) noted complaints of upper and lower back pain with bilateral leg numbness and weakness with right leg pain symptoms beginning in February 2005. The CI reported the leg pain was intermittent at first, but worsened and occurred every day as did numbness with sitting or walking too long.  On examination a “large amount of bilateral thoracic and lumbar spasm” was recorded.  A range or motion (ROM) examination performed at the Pain Medicine consultation on 8 June 2005 showed flexion to be “90% of normal” and extension, and rotation “100% of normal.”  Strength, motor reflexes and sensation were normal.  Straight leg raises were unremarkable to 90 degrees.  Epidural steroid injections (ESI’s) were recommended along with deep massage.  Thoracolumbar ROM measurements performed by physical therapy (PT) on 10 June 2005 showed, after repetition, flexion of 40 degrees (normal 90) and a combined ROM of 175 degrees (normal 240).  The measurements were taken using both a goniometer and inclinometer.  Electrodiagnostic studies performed on 26 August 2005 were abnormal due to bilateral denervation of L5 and S1 muscles and paraspinals consistent with bilateral L5 and S1 radiculopathy.  At the neurology consult on 9 September 2005, the motor examination showed no atrophy, but the CI did have “some weakness of the dorsiflexors of the left foot at about 5-/5.”  Reflexes were somewhat diminished at the ankles on both sides and there was diminished sensation in the bilateral L5 and S1 nerve root distribution. A straight leg raise test (to determine nerve root irritation) was negative.  There were severe spasms and tenderness, but gait and coordination were normal.  

At the VA Compensation and Pension (C&P) examination in May 2006, performed 4 months after separation, the CI reported back pain with numbness and pain radiating down both legs (left greater then right).  On examination, the CI displayed a normal gait and spinal contour.  Radiation of pain on movement was absent.  Muscle spasms and tenderness were noted.  A straight leg raise test was negative on both sides.  Sensation and motor strength of the lower extremities were normal.  Reflexes of the knees and ankles were 1+.  Thoracolumbar ROM measurements showed flexion of 80 degrees (normal 90) and a combined ROM of 200 degrees (normal 240) after repetition.  There was no pain, fatigue weakness, lack of endurance or incoordination after repetitive use.

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  
DOS 20051221
Thoracolumbar ROM
(Degrees)	Pain Medicine ~6 Mo. Pre-Sep
(20050608) p.79	
PT ~6 Mo. Pre-Sep
(20050610) p.87	VA C&P ~4 Mo. Post-Sep
(20060503) p.246	
Flexion (90 Normal)	90% of normal	40,40,40 	0-80	
Extension (30)	100 % of normal	30 (50,48,45)	0-20	
R Lat Flexion (30)	100% of normal	30 (38,32,37)	0-30	
L Lat Flexion (30)	100% of normal-	15 (22,20,15)	0-30	
R Rotation (30)		30 (50,49,51)	0-20	
L Rotation (30)		30 (50,50,52)	0-20	
Combined (240)		175	200	
Comment	Pain right iliac crest, bilateral thoracic region, and over the thoracolumbar ligaments, right greater than left	Painful Motion;
inclinometer and goniometer used		
§4.71a Rating	-	20	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5243 code (intervertebral disc syndrome), citing flexion of 69 degrees (passive measurement), tenderness and spasm with a normal gait.  The VA also assigned a 10% rating using the 5243 code based on the VA C&P examination 4 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees or the combined ROM greater than 120 degrees but not greater than 235 degrees.   The VA did not service-connect lumbar radiculopathy.

The Board noted that the limitation of thoracolumbar motion recorded in the PT examination in June, 6 months prior to separation, met the threshold for a 20% rating; however, the ROM examination was done using both an inclinometer and goniometer, making the examination’s probative value compromised.  The ROM descriptions noted in the Pain Medicine consult of flexion “90% of normal” and extension and rotation “100% of normal” were sufficiently specific and detailed to conclude the limitation of motion did not approach the less than 60 degrees limitation (out of 90 degrees) to support a 20% rating.  This consult was also consistent with the subsequent VA C&P examination performed 4 months after separation which recorded flexion of 80 degrees and a combined ROM of 200 degrees, supporting a 10% rating; therefore, the Board placed greater probative value on the VA examination.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the VA C&P examination.  The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy of the right lower extremity.  Electrodiagnostic studies supported some level of radicular nerve irritation or involvement, but physical examinations (neurosurgery, pain medicine and VA C&P) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board concluded that an additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the lumbar condition.  

Radiating Pain and Slight Weakness…EMG with Mild Radiculopathy of the Left L5-S1 Root.  According to STRs and the MEB NARSUM, the CI’s complained of intermittent back pain radiating into his legs with numbness and weakness in his left leg and foot began in October 2003 after a 4-mile run.  Electrodiagnostic studies performed on 26 August 2005 were abnormal due to bilateral denervation of L5 and S1 muscles and paraspinals consistent with bilateral L5 and S1 radiculopathy.  At the MEB examination the CI reported back pain and numbness and tingling down the left side.  

At the VA Compensation and Pension (C&P) examination in May 2006, performed 4 months after separation, the CI reported back pain with numbness and pain radiating down both legs (left greater then right).  On examination, the CI displayed a normal gait and spinal contour.  Radiation of pain on movement was absent.  Muscle spasms and tenderness were noted. Straight leg raise test was negative on both sides.  Sensory and motor strength of the lower extremities were normal.  Reflexes of the knees and ankles were 1+.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5243-8520 code (intervertebral disc syndrome-incomplete mild paralysis), citing EMG findings of only left sided radiculopathy.  The VA originally did not service-connect radiculopathy, but based on a subsequent VA Board of Appeals decision dated 24 April 2012, the VA assigned a 10% rating using an analogous 8599-8520 code for both left and right lower extremities, citing mild incomplete paralysis.  Board members contemplated whether the radiating pain with slight weakness warranted a rating higher than 10%; however, in the absence of moderate motor weakness or a moderate sensory deficit, the CI‘s condition did not rise to a 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the mild radiculopathy of the left lower extremity.  

BOARD FINDINGS:  In the matter of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left lower extremity radiculopathy condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20160018424 (PD201404357)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA